MEDICARE: DR. MANJUMMELKUDIYIL P KURUVILLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	128155-1	NY

General Provider Information

NPI Number	:	1790816510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MANJUMMELKUDIYIL P KURUVILLA MD

Provider Business Mailing Address
First Line	:	15 CEDAR RIDGE LN
Second Line	:
City	:	DIX HILLS
State	:	NY
Zip	:	11746-7936
Country	:	US
Telephone Number	:	631-968-9102
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 4TH AVE
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-7908
Country	:	US
Telephone Number	:	631-968-9102
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	10/05/2012

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